This piece appeared in the Concord Monitor on 1/24/2016 under the title “No games on state Medicaid expansion”.

As New Hampshire’s Legislature kicks off, there is probably no issue of greater significance for the state than the future of its Medicaid expansion. More than 46,000 people are now enrolled in the New Hampshire Health Protection Program, our Medicaid expansion.

It is estimated that by the end of the year, 58,000 New Hampshire residents will have coverage. That is a major chunk of low income residents who were previously uninsured. It is not an overstatement to say that before the Medicaid expansion, these folks often could not get inside any doctor’s office.

The Legislature now has to decide whether to continue the Medicaid expansion. The program sunsets on December 31, 2016. Without reauthorization, it dies and all those who became medically insured would become uninsured again. The state would also lose an enormous amount of federal money: hundreds of millions of dollars per year moving forward.

So far, New Hampshire has taken quite an independent path in crafting a Medicaid expansion that fits our state. The state has used federal funds to offer private sector health coverage to lower income, uninsured residents. This New Hampshire-specific approach is not the conventional way and it required a federal waiver.

Medicaid is a joint federal-state partnership and all states with a Medicaid program must abide by federal guidelines administered by the Center on Medicare and Medicaid Services known as CMS. At the same time, federal rules allow some freedom for states to tinker as long as the federal government ultimately approves the plan.

I think it is fair to say that early reports have found our Medicaid expansion highly successful. Besides the thousands who were previously uninsured and became insured, there has been a noticeable decrease in uncompensated care for health care providers. A study by the New Hampshire Hospital Association has shown a marked reduction in uninsured inpatient, outpatient and emergency room visits.

Less uncompensated care also reduces pressure for health insurance premium increases – not just for families and individuals but for businesses. This is an under-appreciated fringe benefit, and one significant reason that New Hampshire’s business community supports extending Medicaid expansion.

Simply put, the Medicaid expansion is a win-win. Providers get paid and consumers get coverage. Considering the mental health and opioid crisis in our state, this coverage could not be more timely. Medicaid coverage is an essential tool in these fights. It provides access to care so desperately needed for many facing addiction and mental health traumas.

Up until now, the Medicaid expansion has been paid for 100% by federal dollars. New Hampshire has not had to pony up any financial contribution which has been a phenomenal deal for the state.

Looking to the future, where things start getting sticky is the funding formula that includes a state contribution in dollars. After the first three years of the expansion, the state is obligated to kick in a small percentage of the cost. In 2017, the federal government will pay 95% of the cost; in 2018 94%; in 2019 93%; and in 2020 and beyond 90%. The feds never pay less than 90% of the total cost. So next year the state would have to pay 5% of the cost and it would gradually go up to 10% by 2020.

For perspective, in 2017 and in return for a $25 million state contribution, New Hampshire’s Medicaid expansion is projected to bring $475 million in federal funds back home, to circulate in our economy in beneficial ways.

I would submit that this is still a wonderful deal for our state. We will be receiving a very great benefit at a small fraction of the cost in state dollars. There is a weird irony in those who profess personal responsibility also wanting the state to get a free ride from the federal government on a program that provides so much benefit to New Hampshire. Doesn’t personal responsibility imply that our state pay some cost? We have skin in the game.

Not surprisingly, Republicans and Democrats have some different ideas about what the future Medicaid expansion should look like. Two bills, HB 1696, a Republican bill, and HB 1690, a Democratic bill, have been introduced and assigned to the House Health and Human Services Committee.

I will touch on some of the bill differences. The Republicans favor a 4 year, time-limited Medicaid expansion with a new sunset date of December 31, 2020. The Democrats propose to make the Medicaid expansion permanent.

The Republicans are advocating for low-income enrollees to pay premiums. Enrollees with incomes from 100% to 138% of the federal poverty level (that is $11,000 to $16,000 a year for an individual, and from $24,000 to $33,000 a year for a family of 4) would pay $25 per month. Enrollees with incomes from 0% to 100% of the federal poverty level (up to $11,000 a year for an individual and up to $24,000 a year for a family of 4) would pay $10 per month. The suggested premiums are higher than any, to date, that have been allowed by the federal government.

The Republican bill also contains a termination and lockout provision for any enrollee who fails to make premium payments within 60 days of when it is due. Those unable to pay the premium would face a 6 month lockout where they could not re-enroll. As applied to all enrollees, the proposed penalty design is more severe than any that CMS has ever allowed.

The Republican bill also imposes work requirements on Medicaid recipients. While there is legitimate room for policy discussion about the merits of such a proposal for able-bodied persons not caring for children or ailing family members, the reality is that federal law does not allow such a requirement and CMS has never approved a state waiver proposal that includes it.

The Democratic bill contains none of these provisions.

It remains unclear if the federal government, through CMS, would grant a waiver with the type of provisions that appear in the Republican bill. They impose conditions that are more stringent than have been previously allowed by CMS.

A question that emerges: would the Republican leadership in the State House and Senate be willing to sacrifice the entire Medicaid expansion if what appears to be a pet ideological laundry list is not okayed by the federal government? It is not clear if the Republican leadership, in an election year, is simply throwing red meat at its right wing base or if it intends to use the additional preconditions as justification for scuttling the expansion.

It is significant that the Republicans have not pointed out what is wrong with the expansion as it currently functions.

One observation I would make about the Republican bill: it does not recognize the degree of poverty poor people face. The overriding brutal fact of life for people living at or close to the federal poverty level is lack of income which leads to choices about what bills get paid. Basic necessities like housing, utilities, and food can reduce available cash to zero. Other costs like child care or transportation are necessary for employment. If money is short, preventing homelessness or repairing one’s car to get to and from work is likely a higher value than paying medical premiums.

Experience has shown that low-income people are very sensitive to even nominal increases in medical out-of-pocket costs. There is a wealth of research supporting that conclusion. I would cite the Kaiser Commission on Medicaid and the Uninsured. In February 2013, they produced an overview of research findings relative to premiums and cost-sharing in Medicaid. The Kaiser Commission concluded that premiums act as a barrier to obtaining and maintaining coverage for low-income populations. It is common for premiums to result in coverage loss and the elimination of access to needed care, leading to adverse health consequences.

State savings from cost-sharing and premiums are due more to eligible people dropping or declining coverage than to increases in state revenue. Significantly, early results from states charging premiums to Medicaid expansion enrollees indicate that the administrative cost of collection exceeds any money actually realized from the premiums.

One would hope the Republican leadership would familiarize itself with the substantive research showing why premiums in Medicaid are generally seen as a failure. Their current bill appears to be more rooted in political posturing than evidence-based public policy.

No doubt party positions will evolve as the legislative session unfolds. Recognizing the paramount importance of maintaining the Medicaid expansion, I, for one, hope the parties can reach a fair compromise. The Medicaid expansion, which helps so many, deserves better than to be reduced to a political game.

In the last week, I got to visit my son Josh and his wife Nancy in Los Angeles where they live. We did get around. Here is my selection of best places we got to:

The Last Bookstore
Located in downtown L.A. in a space that used to be a bank, this bookstore, ironically named, has volume. The place is kind of dark, poorly lit, but there are many new and used books. I didn’t have enough time to look around that much but the literature and classic literature section were especially large. It looked like they put counterculture, aliens, and horror all in the same bank vault – an interesting commingling. I found a good book on Latino history by Juan Gonzalez titled Harvest of Empire. For book lovers, worth checking this place out.

Madcapra Falafel at Grand Central Market
This place may have the best falafel ever. At least the best I have tasted. They had four falafel options. I tried the yellow which included falafel with feta, harissa, cucumbers, pickled sweet peppers and parsley stuffed in flatbread. The sandwich had heft, was very tasty, and was really more than one meal. The cost was very reasonable and the service was good. I would mention the cardoman coffee too. Any coffee lover would dig it.

Skylight Books
I have to say I love this bookstore and I always try to get to it whenever I get to L.A.. It is great to see a legit independent bookstore that survives. I would think Amazon would put all out of business. Invariably, I find books I have not seen elsewhere. It has a superior non-fiction, politics and social science section, including progressive politics. I always leave with a list of books I should check out. Most of the books I never heard of before I walked in.

Daikokuya Sawtelle
I admit I don’t know from ramen. I had never been to a ramen house before. I think of ramen in little packages where the choice is beef or shrimp. New Hampshire has no ramen houses. The ramen broth at this place was very rich and flavorful. Bowl portions were generous and the noodles had good texture. For dumpling fans, I also would recommend the gyoza. Place is not expensive. The interior was cooly designed to resemble an Asian street scene.

Hiking to Lizard Rock at Thousand Oaks
It was a cool morning and the air was very fresh as we headed out. The hike is pretty easy but the views were good. Not that much vertical. The landscape is so different from the east. Very arid, plenty of cactus. I did not see any rattlesnakes but Josh assured me they were around. You do not see anything like this in New England.

I have to admit that Alex Kershaw’s book, Avenue of Spies, grabbed me right from the start and it did not let go. It is a true story that reads like a fictional thriller. You could call it an adventure story, a love story, or a tale of remarkable bravery and heroism. It is all of those.

Set against World War II in Nazi-occupied Paris, Avenue of Spies tells the story of an American surgeon Sumner Jackson, his Swiss-born wife Toquette, and their son Philip. Much of the story comes from Kershaw’s extensive interviews with Philip Jackson.

The Jacksons lived on the same street in Paris as numerous Gestapo henchmen. Right down the street was the Gestapo headquarters inhabited by an assortment of fanatics, sadists and psychopaths. In the summer of 1943, Toquette joins the French Resistance, brings the whole family into the fight against the fascists, and operates right under the nose of the Nazi leaders in Paris. The fact that Sumner Jackson was a doctor provided cover for the various comings and goings of Resistance members into his house. As a doctor, he could explain the visits as patient medical appointments.

Avenue of Spies takes you into that world with an astonishing degree of realism. You could feel the danger. You also could appreciate the bravery. So many of the French collaborated with the Nazis. The Jackson family risked everything and they paid a big price. I am reminded of an Edward Abbey quote I have always liked:

“We live in the kind of world where courage is the most essential of virtues; without courage, the other virtues are useless.”

As I noted, a truly malevolent collection of Nazis moved into Avenue Foch, the fashionable street where the Jacksons resided. Many of the previous residents exited before the Nazi arrival in 1940. The Jacksons certainly had an opportunity to leave but they ultimately decided to stay.

Among the Nazis who moved into the neighborhood, there was Theo Dannecker, head of the Gestapo’s Jewish Affairs Office in Paris. Dannecker was a central figure in the effort to exterminate French Jews. Dannecker worked closely with SS colonel Adolf Eichmann, the architect of the Final Solution.

And there was Helmut Knochen, known as Dr. Bones. Knochen, a proud member of the SS and Gestapo chief in Paris, worked tirelessly to destroy all opposition to German rule in France. He worked under Heinrich Himmler, the Supreme head of the SS, to eliminate all Resistance networks in France. In his role, Knochen recruited a private army of criminals to capture, torture and murder all perceived opponents. Knochen trawled the prisons to find the toughest career criminals and sociopaths who would do Nazi dirty work.

The story includes an interesting discussion of the disagreement among Nazi leaders about how to accomplish the extermination of French Jews.. Dannecker wanted the SS to round up the Jews. Knochen wanted the French themselves to do it. Knochen got his way. On the night of July 16, 1942, 13,152 Parisian Jews, including 4000 children, were rounded up by the French police.

The Nazis hid their true intentions. They created the fiction that those rounded up were headed to a new Jewish state being created in the East.

As Kershaw says, the Jacksons were living in the heart of a vast web of informers, spies and mass murderers.

While the Jackson family was appalled by the Nazis and the Milice, the French fascist paramilitary, they had no choice but to maintain composure. Their situation required immense sangfroid.

Dr. Jackson rose to the challenge and was quite the operator. I should add that Toquette and Philip were equally brave. Dr. Jackson maintained ties with General Rene de Chambrun, godson of Marshal Petain, the Vichy leader. General de Chambrun was influential and had connections with authorities. Dr. Jackson effectively used this relationship to protect his hospital, the American Hospital in Paris, and to keep the Germans at bay.

Dr. Jackson was able to do this for a good part of the war years and he saved many lives. He secretly helped Americans who were escaping the Germans. He falsified records to list recovered prisoners as deceased. He helped patients disappear. He hid French-Jewish officers and made sure there was no record of their stay in his hospital.

The Jacksons certainly knew the risks they were taking in joining the Resistance. Neighbors on Avenue Foch kept their windows closed so they did not have to hear the screams of the torture victims.

Without saying too much about the ending, I will say that the Jacksons’ luck ran out in May 1944. The last third of the book is devoted to the experiences of the family in the Nazi concentration camps. Toquette lands in Ravensbruck camp for women. Kershaw captures the depravity of the Nazis and the extraordinarily awful conditions endured by the prisoners. The brutality, the hunger, the cold, the complete lack of humanity, pity or kindness demonstrated by the Nazis: it is still hard to read about, even now.

There is a quote toward the end from Jacques Delarue, the author of a book on the Gestapo.

“It was a world where people exterminated for pleasure and where the murderers were treated as heroes. It already seemed far away, like a nightmare one would prefer to forget. And yet the poisoned yeast is still ready to rise. Men have not the right to forget so quickly. They have not the right. Never…”

Philip Jackson lived to testify in war crimes trials in 1946. He testified in a trial of fourteen SS officers who had been in charge of Neuengamme labor camp where he and his father had been held. Jackson pointed out the Nazis he personally saw commit crimes. The defense attorney for the Nazis argued that his clients were “tools” and not responsible. The Nazis in this trial were sentenced to death. Kershaw wrote that the Nazis showed not even a shred of regret or remorse.

Helmut Knochen, the Gestapo chief in Paris, was sentenced to death in 1947. Incredibly, he escaped hanging. This was a person who played a major role in sending almost 80,000 Jews to their deaths. Knochen had argued: “Neither I, nor one of my subordinates could have acted otherwise, without being condemned to death immediately.”

Knochen was sentenced to death a second time during the Cold War. Knochen’s death sentence was commuted to life imprisonment. Then, in 1962, French President Charles de Gaulle inexplicably pardoned Knochen. Knochen returned to Germany and lived to be 93 years old before he died peacefully. He said that the extermination of the Jews by Hitler was the greatest crime in history but he claimed that he did not know the Jews of France who were deported East were being murdered.

The escape of so many Nazis from the fate that they so richly deserved never ceases to amaze. It is hard to understand how the fatuous and transparently false arguments made by Knochen and other Nazis were given any credence.

One other story I would mention: Kershaw tells how Hitler wanted Paris completely destroyed at the end of the war. Even though it was clear the Nazi cause was lost, Hitler madly ordered they fight to the last man. He wanted all the great monuments and bridges blown up. Hitler wanted Paris, the most beautiful city in the world, left a vast ruin. As insane as the Nazis were, it turned out that some of their generals did not want to go down in history as the destroyer of Paris.

Kershaw quotes the French Resistance leader, Jean-Pierre Levy:

“We lived in the shadows as soldiers of the night, but our lives were not dark and martial…There were arrests, torture and death for so many of our friends and comrades, and tragedy awaited all of us just around the corner. But we did not live in or with tragedy. We were exhilarated by the challenges and rightness of our cause.”

It was inspiring to read about and feel the atmosphere of that humane heroism.